S6090 An Unsual Case of Gastric Outlet Obstruction: Duodenal Hematoma From Pancreatic Cancer Infiltration

Introduction: Intramural duodenal hematoma (DH), a rare pathology primarily associated with blunt trauma in pediatrics and young adults or with spontaneous bleeding due to anticoagulation usage, can cause a bulge into the intraluminal space. Osmotic fluid shifts may increase the size of the DH leading to gastric outlet obstruction (GOO). Here, we present the case of a 62-year-old man with a DH causing GOO secondary to pancreatic adenocarcinoma. Case Description/Methods: A 62-year-old man presented with a 1-day history of abdominal pain, decreased flatus, and non-bilious emesis that transitioned to hematemesis. Computed tomography revealed an 11 cm intramural DH causing GOO as well as a 2.1 cm pancreatic head lesion causing upstream ductal dilatation. Esophagogastroduodenoscopy found a severe extrinsic deformity in the duodenal bulb and in the second portion of the duodenum, consistent with hematoma. Followup endoscopic ultrasound showed a 2.3 × 2.2 cm hypoechoic irregular mass in the pancreatic head. Biopsy and elevated CA 19-9 confirmed pancreatic adenocarcinoma. Staging computed tomography scans did not reveal metastases. He underwent gastrojejunostomy bypass. Discussion: DH caused by pancreatic adenocarcinoma is a rare etiology of GOO. Multiple theories for the pathophysiology of pancreatic cancer leading to DH exist including pancreatic enzymes causing tissue degradation, vascular erosion, and hematoma development. Computed tomography scans, the diagnostic modality of choice for adults, characteristically show a duodenal mass with fluid density indicative of blood. Since DHs typically self-resolve, treatment focuses on conservative management with bowel decompression and rest monitored with computed tomography scans. Consistent with protocol, the patient was treated conservatively. However, the etiology of pancreatic adenocarcinoma leading to DH and GOO supports surgery. This case highlights the importance of a broad differential diagnosis for GOO, including rare causes such as DH. Etiology dictates treatment.